Background: Hypertension is considered to be one of the most common chronic diseases afflicting the world population that is associated with increased mortality. It is estimated that more than a quarter of the world’s adult population had hypertension in the year 2000, and that such prevalence increases with age all over the world.

Objective: To identify and compare the hypertension associated neurological and non-neurological signs and symptoms among different age
groups.

Methods: A cross-sectional multicenter study was carried out among patients with self-reported history of hypertension and on antihypertensive
medication. The written informed consent was obtained from the patients after taking ethical approval. A total of 174 patients aged
18 years or above were included in the study using convenient sampling technique and the duration of study was from Jan 2017 till June 2017.
Patients were divided in two groups according to their ages i.e. ≤40 years and >40 years old. A detailed history was taken from each patient about
hypertension associated symptoms with the help of a structured questionnaire. Blood pressure was measured using sphygmomanometer with
stethoscope to assess hypertension level. The patients with history of diabetes, thyrotoxicosis and liver diseases were excluded from the study. Date
was analyzed by using SPSS version 20. Chi square and fisher exact test was used to assess the significance.

Results: A higher percentage of the patients in the >40 years age group had severe systolic and diastolic hypertension than patients in the
≤40years age group (4.0% vs. 1.4% and 9.0% vs. 1.4% respectively).Among the patients aged ≤40 years only fatigue (p=0.049) was significantly
associated with systolic blood pressure while among patients aged >40 years severity of headache (p=0.026), dyspnea (p=0.022), fatigue (p=0.003)
and confusion (p=0.006) were significantly associated with systolic blood pressure whereas edema (p=0.016) and fatigue (p=0.019) were
significantly associated with diastolic blood pressure.

Conclusion: The symptoms significantly associated with systolic or diastolic hypertension increased with the increasing age of the patients.
These findings give us local evidence emphasizing the need to focus more on the management of older hypertensive patients.

Hypertension is considered to be one of the most common
chronic diseases afflicting the world population that is associated
with increased mortality.[1] The comparative Risk Assessment
Collaborating Group has identified hypertension as the leading
global risk factor for mortality and as the third leading risk
factor for disease burden.[2] One of the most common causes
of death due to Hypertension is the cardiovascular disease
making hypertension the most common reversible risk factor
for cardiovascular diseases.[3,4] It is estimated that more
than a quarter of the world’s adult population-0.972 billionhad
hypertension in the year 2000, that both men and women
have similar overall prevalence of hypertension, and that
such prevalence increases with age all over the world. Global
hypertension prevalence is currently 26% which is expected
to rise to 29% by the year 2025. The predictions for 2025 are
based on the assumption that the country, age, and sex specific
prevalence estimates will remain constant.[5] According to the
World Health Organization, the total prevalence of high blood
pressure in Pakistan is estimated to be 25.2% (25.6% in males
and 24.8% in females).[6]

Hypertension is defined as a systolic blood pressure (SBP)
of 140 mmHg or more, or a diastolic blood pressure (DBP) of
90 mmHg or more, or taking antihypertensive medication.[7]
Based on the recommendations of the Seventh Report of the
Joint national committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC 7), Blood Pressure
for adults aged 18 years or older has been classified into four
categories as normal, pre-hypertension, stage 1 and stage 2.
Normal indicates a systolic blood pressure of < 120 mmHg; and
a diastolic < 80 mmHg. Pre-hypertension means a systolic blood
pressure of 120-139 mmHg; while a diastolic of 80-89 mmHg.
Stage 1 reads a systolic of 140-159 mmHg; and a diastolic of 90-
99 mmHg. Stage 2 is considered to be severe and gives a systolic
of 160 mmHg or greater; and a diastolic of 100 mmHg or greater.
[8] WHO recognizes three levels of hypertension as levels 1, 2
and 3. Level 1 means a systolic BP between 140 and 159 mmHg
and a diastolic BP between 90 and 99, level 2 means a systolic BP
between 160 and 179 mmHg and a diastolic BP between 100-109
mmHg while level 3 means a systolic BP of 180 and above and a
diastolic BP of 110 mmHg and above.[9]

There are two types of hypertension namely essential and
secondary. Essential hypertension can be defined as a rise in
blood pressure of unknown cause that increases risk for cerebral,
cardiac, and renal events.[10] Secondary hypertension is defined
as increased systemic blood pressure due to an identifiable cause.
Only 5–10% of patients suffering from arterial hypertension
have a secondary form, whereas the vast majority has essential
(idiopathic or primary) hypertension.[11]

Hypertension can present with severe clinical presentation to
an even asymptomatic picture depending upon the several factors
such as age, gender, and severity of hypertension. Our objective
was to find associations between the degree of hypertension and
the severity of the associated symptoms among different age
groups.

Patients and Methods

A cross-sectional multicenter study was carried out among
patients with self-reported history of hypertension and on antihypertensive
medication. After taking ethical approval from Urban
Hospital, North Karachi. A total of 174patients aged 18 years or
above were included in the study using convenient sampling
technique. Patients were divided in two groups according to their
ages i.e. ≤40 years and >40 years old. A detailed history was taken
from each patient about hypertension associated symptoms with
the help of a structured questionnaire. The questionnaire was
designed based on 12 major or most frequently encountered
symptoms by the hypertensive patients. The site, duration, and
severity of each symptom were documented. Each symptom was
graded from mild to severe to assess the severity of the symptoms.
The presence of edema was noted with its laterality and grading.
The appearance of chest pain was noted with its severity. The
problems of vision were noted and classified according to the loss
in field of vision. The history of epistaxis and urinary symptoms
were noted with frequency. Few additional symptoms such as
nausea, sleep apnea, palpitations, fatigue and confusion were
also assessed subjectively. Blood pressure was measured using
sphygmomanometer with stethoscope to assess hypertension
level.

To classify hypertension, the British Hypertension Society
Classification, consistent with the European Hypertension
Society and World Health Organization International Society
of Hypertension, was used.[12]Similar to WHO classification, it
also recognizes three grades of hypertension as grade 1, 2 and
3. Grade I (Mild hypertension) means a systolic BP between 140
and 159 mmHg and a diastolic BP between 90 and 99, Grade II
(Moderate hypertension) means a systolic BP between 160 and
179 mmHg and a diastolic BP between 100-109 mmHg whereas
Grade III (Severe Hypertension) means a systolic BP of ≥ 180
mmHg and a diastolic BP ≥ 110 mmHg.

Patients with history of diabetes, cardiac events, neurological
disorders, cluster headache, gastrointestinal disease, visual
problems, epistaxis before they were diagnosed with HTN and
morbid obesity were excluded from the study. Patients with
isolated systolic hypertension were also excluded from the study

For statistical analysis, statistical package for social sciences
(SPSS version 21) was used. Chi-square test was performed
to assess associations between various study variables and
hypertension across different age groups. P-values less than 0.05
were considered statistically significant. The duration of the
study was 6 months.

Results

The study results showed that the mean age of patients aged
≤40 years was 31.19±7.44 years whereas that of patients aged
>40 years was 54.34±9.13 years. A majority of patients aged
≤40 years were females whereas that of patients aged >40 years
were males (58.1% and 62.0% respectively). A higher percentage
of the patients in the >40 years age group had severe systolic
and diastolic hypertension than patients in the ≤40years age
group (4.0% vs. 1.4% and 9.0% vs. 1.4% respectively). Both
the mean systolic and diastolic blood pressures were slightly
higher in patients aged ≤40 years than those>40 years old
(148.23±13.62 mmHg vs. 146.11±16.74 mmHg and 92.86±5.02
mmHg vs. 91.41±10.24 mmHg respectively). The mean duration
of hypertension was higher in patients belonging to the older age
group (4.62±3.51 years vs. 4.11±2.99 years) whereas a slightly
higher percentage of them were smokers as well (15.0% vs.
8.1%). A higher percentage of the older patients had positive
clinical history of headache (58.0% vs. 40.5%) whereas the
most common site of headache was occipital in the younger and
temporal in the older age group (46.7% and 24.1% respectively).
The severity of headache was moderate in a majority of the
patients belonging to the younger as well as the older age group
(56.7% and 44.8% respectively). A higher percentage of the
patients belonging to the older age group had vertigo than the
younger age group (44.0% vs. 21.6% respectively) whereas a
similar majority of both age groups reported its severity to be
mild (68.8% and 68.9% respectively). A higher percentage of the
older patients had edema (28.0% vs. 17.6%) but it was seen to be
bilateral in a similar percentage of both the younger and the older
age groups (61.5% and 64.3% respectively). The edema was of
moderate grading in a higher percentage of the younger patients
(61.5% vs. 39.3%). A higher percentage of the older patients gave
a positive history of chest pain (30.0% vs. 17.6%) and a higher
percentage of those patients in the older age group needed
pain relieving medication for it to subside (58.6% vs. 30.8%). A
markedly higher percentage of patients belonging to the older
age group gave a positive history of vision problems (54.0%
vs. 24.3%) whereas the most common type of vision problem
in both the younger and the older patients was dark spots in
the field of vision (44.4% and 40.0% respectively). A markedly
higher percentage of patients belonging to the older age group
gave a positive history of dyspnea (51.0% vs. 25.7%) whereas
most of both the younger and the older patients reported it to
be of moderate severity (47.4% and 49% respectively).Though
an almost similar percentage of patients belonging to both the
younger and the older age groups suffered from nausea (21.9%
and 19.0% respectively),a markedly higher percentage of older
patients reported to suffer from sleep apnea, irregular heartbeat/
palpitation, fatigue and confusion(52.0% and 27.0%, 43.0% and
23.0%, 72.0% and 45.2% and 62.0% and 28.8% respectively)
[Table 1].

1n=30 and 58 in ≤40 years and >40 years old respectively2n=16 and 45 in ≤40 years and >40 years old respectively3n=13 and 28 in ≤40 years and >40 years old respectively4n=13 and 29 in ≤40 years and >40 years old respectively5n=18 and 50 in ≤40 years and >40 years old respectively6n=19 and 51 in ≤40 years and >40 years old respectively7n=73 and 100 in ≤40 years and >40 years old respectively

The study findings further showed that among the patients
aged ≤40 years only fatigue (p=0.049) was significantly associated
with systolic blood pressure where those who had mild systolic
hypertension very more likely to suffer from fatigue than those
who had moderate/severe systolic hypertension (50.0% vs.
18.2% respectively). None of the other variables were found to
be significantly associated with either systolic or diastolic blood
pressure in this age group [Table 2].

Among patients aged >40 years severity of headache
(p=0.026), dyspnea (p=0.022), fatigue (p=0.003) and confusion
(p=0.006) were significantly associated with systolic blood
pressure where those who had mild systolic hypertension were
less likely to have mild/moderate headache, dyspnea, fatigue
and confusion than those who had moderate/severe systolic
hypertension (50.0% vs. 80.0%, 43.7% vs. 69.0%, 63.4% vs.
93.1% and 53.5% vs. 82.8% respectively) whereas edema
(p=0.016) and fatigue (p=0.019) were significantly associated
with diastolic blood pressure where those who had mild diastolic
hypertension were less likely to have edema and fatigue than
those who had moderate/severe diastolic hypertension (22.1%
vs. 47.8% and 66.2% vs. 91.3% respectively).None of the other
variables were found to be significantly associated with either
systolic or diastolic blood pressure in this age group [Table 3]

Table 2: Relationship between blood pressure and patients’ signs and symptoms in ≤40 year’s age group

Variables

≤40 Years (n=74)

SBP

DBP

Mild Hypertension

Moderate/Severe Hypertension

Mild Hypertension

Moderate/Severe Hypertension

Frequency (%)

Frequency (%)

Frequency (%)

Frequency (%)

Gender

Male

26(41.3)

5(45.5)

29(42.0)

2(40.0)

Female

37(58.7)

6(54.5)

40(58.0)

3(60.0)

P

0.523*

0.653*

Smoking

Yes

6(9.5)

Nil

6(8.7)

Nil

No

57(90.5)

11(100)

63(91.3)

5(100)

P

0.367*

0.647*

Clinical History of Headache

Yes

27(42.9)

3(27.3)

28(40.6)

2(40)

No

36(57.1)

8(72.7)

41(59.4)

3(60)

P

0.266*

0.678*

Severity of Headache

Mild/Moderate

20(74.1)

2(66.7)

20(71.4)

2(100)

Severe

7(25.9)

1(33.3)

8(28.6)

Nil

P

0.621*

0.531*

Vertigo

Yes

13(20.6)

3(27.3)

15(21.7)

1(20.0)

No

50(79.4)

8(72.7)

54(78.3)

4(80.0)

P

0.44*

0.706*

Edema

Yes

12(19.0)

1(9.1)

13(18.8)

Nil

No

51(81.0)

10(90.9)

56(81.2)

5(100)

P

0.38*

0.369*

Laterality of Edema

Bilateral

7(58.3)

1(100)

8(61.5)

Nil

Unilateral

5(41.7)

Nil

5(38.5)

Nil

P

0.615*

….

Grading of Bilateral Edema

Mild/Moderate

8(66.7)

1(100)

9(69.2)

Nil

Severe

4(33.3)

Nil

4(30.8)

Nil

P

0.692*

….

Chest Pain

Yes

12(19.0)

1(9.1)

13(18.8)

Nil

No

51(81.0)

10(90.0)

56(81.2)

5(100)

P

0.38*

0.369*

Vision Problems

Yes

17(27.0)

1(9.1)

18(26.1)

Nil

No

46(73.0)

10(90.9)

51(73.9)

5(100)

P

0.189*

0.237*

Dyspnea

Yes

17(27.0)

2(18.2)

19(27.5)

Nil

No

46(73.0)

9(81.8)

50(72.5)

5(100)

P

0.422*

0.216*

Severity of Dyspnea

Mild/Moderate

12(70.6)

1(50.0)

13(68.4)

Nil

Severe

5(29.4)

1(50.0)

6(31.6)

Nil

P

0.544*

….

Nausea

Yes

14(22.6)

2(18.2)

15(22.1)

1(20.0)

No

48(77.4)

9(81.2)

53(77.9)

4(80.0)

P

0.549*

0.700*

Sleep Apnea

Yes

17(27.0)

3(27.3)

19(27.5)

1(20.0)

No

46(73.0)

8(72.7)

50(72.5)

4(80.0)

P

0.621*

0.589*

Irregular Heartbeat/Palpitation

Yes

15(23.8)

2(18.2)

17(24.6)

Nil

No

48(76.2)

9(81.8)

52(75.4)

5(100)

P

0.512*

0.260*

Fatigue

Yes

31(50.0)

2(18.2)

31(45.6)

2(40.0)

No

31(50.0)

9(81.8)

37(54.4)

3(60.0)

P

0.049*

0.592*

Confusion

Yes

18(29.0)

3(27.3)

19(27.9)

2(40.0)

No

44(71.0)

8(72.7)

49(72.1)

3(60.0)

P

0.609*

0.448*

*Fisher’s Exact Test

Table 3: Relationship between blood pressure and patients’ signs and symptoms in >40 year’s age group

Variables

>40 Years (n=100)

SBP

DBP

Mild Hypertension

Moderate/Severe Hypertension

Mild Hypertension

Moderate/Severe Hypertension

Frequency (%)

Frequency (%)

Frequency (%)

Frequency (%)

Gender

Male

46(64.8)

16(55.2)

47(61.0)

15(65.2)

Female

25(35.5)

13(44.8)

30(39.0)

8(34.8)

P

0.369

0.717

Smoking

Yes

9(12.7)

6(20.7)

10(13.0)

5(21.7)

No

62(87.3)

23(79.3)

67(87.0)

18(78.3)

P

0.235*

0.236*

Clinical History of Headache

Yes

38(53.5)

20(69.0)

43(55.8)

15(65.2)

No

33(46.5)

9(31.0)

34(44.2)

8(34.8)

P

0.156

0.424

Severity of Headache

Mild/Moderate

19(50.0)

16(80.0)

23(53.5)

12(80.0)

Severe

19(50.0)

4(20.0)

20(46.5)

3(20.0)

P

0.026

0.071

Vertigo

Yes

29(40.8)

15(51.7)

34(44.2)

10(43.5)

No

42(59.2)

14(48.3)

43(55.8)

13(56.5)

P

0.32

0.954

Edema

Yes

17(23.9)

11(37.9)

17(22.1)

11(47.8)

No

54(76.1)

18(62.1)

60(77.9)

12(52.2)

P

0.157

0.016

Laterality of Edema

Bilateral

11(64.7)

7(63.6)

12(70.6)

6(54.5)

Unilateral

6(35.3)

4(36.4)

5(29.4)

5(45.5)

P

0.632*

0.321*

Grading of Bilateral Edema

Mild/Moderate

13(76.5)

6(54.5)

14(77.8)

5(50.0)

Severe

4(23.5)

5(45.5)

4(22.2)

5(50.0)

P

0.212*

0.139*

Chest Pain

Yes

19(26.8)

11(37.9)

21(27.3)

9(39.1)

No

52(73.2)

18(62.1)

56(72.7)

14(60.9)

P

0.269

0.276

Vision Problems

Yes

35(49.3)

19(65.5)

40(51.9)

14(60.9)

No

36(50.7)

10(34.5)

37(48.1)

9(39.1)

P

0.14

0.451

Dyspnea

Yes

31(43.7)

20(69.0)

37(48.1)

14(60.9)

No

40(56.3)

9(31.0)

40(51.9)

9(39.1)

P

0.022

0.281

Severity of Dyspnea

Mild/Moderate

19(61.3)

14(70.0)

23(62.2)

10(71.4)

Severe

12(38.7)

6(30.0)

14(37.8)

4(28.6)

P

0.525

0.392*

Nausea

Yes

12(16.9)

7(24.1)

13(16.9)

6(26.1)

No

59(83.1)

22(75.9)

64(83.1)

17(73.9)

P

0.403

0.241*

Sleep Apnea

Yes

33(46.5)

19(65.5)

37(48.1)

15(65.2)

No

38(53.5)

10(34.5)

40(51.9)

8(34.8)

P

0.084

0.148

Irregular Heartbeat/Palpitation

Yes

27(38.0)

16(55.2)

31(40.3)

12(52.2)

No

44(62.0)

13(44.8)

46(59.7)

11(47.8)

P

0.116

0.311

Fatigue

Yes

45(63.4)

27(93.1)

51(66.2)

21(91.3)

No

26(36.6)

2(6.9)

26(33.8)

2(8.7)

P

0.003

0.019

Confusion

Yes

38(53.5)

24(82.8)

45(58.4)

17(73.9)

No

33(46.5)

5(17.2)

32(41.6)

6(26.1)

P

0.006

0.18

*Fisher's Exact Test

*Fisher’s Exact Test

Discussion

The study findings revealed that a higher percentage of the
patients in the >40 years age group had severe systolic and
diastolic hypertension than patients in the ≤40years age group.
Furthermore, and expectedly, the hypertension associated sign
and symptom such as smoking, clinical history of headache,
vertigo, edema, chest pain, vision problems, dyspnea, sleep
apnea, irregular heartbeat/palpitation, fatigue and confusion
were found to be more prevalent in the older than in the younger
age group.

The study findings further showed that in the younger age
group only fatigue was found to be significantly associated with
systolic blood pressure and none of the other variables were
significantly associated with diastolic blood pressure whereas,
as expected, in the older age group a number of signs and
symptoms were found to be significantly associated with systolic
hypertension, such as severity of headache, dyspnea, fatigue and
confusion, as well as with diastolic hypertension, such as edema
and fatigue.

As expected, the study results showed that the older
patients had higher prevalence of severe systolic and diastolic
hypertension than the younger patients, a finding well in line
with the published literature. An earlier study also reported
the prevalence of hypertension to increase with increasing age
with 8% in patients aged 30-39 years to 38% in patients aged
≥60 years.[13] Another study found hypertension prevalence to
show an increasing trend with age with 9.5% in patients aged
15-18 years to 42% in patients aged >60 years.[14] Another
study showed the prevalence of hypertension to increase with
increasing age of the study participants.[15] Yet another study
reported age to be significantly associated with hypertension.
[16]

The study results further showed that the signs and symptoms
associated with hypertension increased with the increasing age
of the study participants. At younger age, only fatigue was found
to have a significant relationship with systolic blood pressure
whereas at older age, severity of headache, edema, dyspnea,
fatigue and confusion all were found to be significantly associated
with either systolic or diastolic hypertension or both. An earlier
study reported headache to be significantly more prevalent
in hypertensive than in normotensive subjects (p< 0.05) but
contrary findings have been reported as well as another study
did not report headache to be significantly associated with
hypertension (OR 1.02, 95% CI 0.79 to 1.30).[17,18] This
difference in findings could be due to different methods of blood
pressure measurement in both studies i.e. Direct versus indirect
auscultatory method. Similarly, an earlier study also reported
dyspnea to be associated with elevated blood pressure though
irrespective of age of the study participants.[19] Unlike this
study, an earlier study did not report any significant difference in
prevalence of weakness among hypertensive and normotensive
subjects though this difference in findings could be due to the use
of different operational definitions of the terminology involved
i.e. Fatigue versus weakness.[17] With regard to the study
findings regarding association of edema, fatigue and confusion
with hypertension, due to lack of relevant data, a comparison
could not be made with the published literature.

Limitation

The use of convenient sampling method, because of financial
and time restraints, was the only limitation of the study.

Conclusion

The symptoms significantly associated with systolic or
diastolic hypertension increased with the increasing age of the
patients. These findings give us local evidence emphasizing the
need to focus more on the management of older hypertensive
patients.

Recommendation

In the light of the study findings it is recommended that
during hypertension screening and management, health care
professionals need to specially focus on the patients aged >40
years as these patients are more likely to have higher number of
hypertension associated sign and symptoms which may require
more intensive management and counseling on part of treating
physicians.